In a Pandemic, Who Gets to Live?

Nov. 12, 2008

By LEE DYE

As if wars and economic crises and natural disasters weren't enough, here's a challenge for some future president that few people even want to think about: Some day, perhaps soon, a president will have to decide whose lives are the most important to save, and whose lives are "nonessential."

This isn't going to be a doomsday story, because most people will survive the next influenza pandemic, which some public health experts believe is past due. It's not a question of "if," it's a question of "when," and one study from Harvard University estimates that the pandemic will kill somewhere between 51 million and 81 million people, mostly in developing countries.

Hundreds of organizations and institutions around the world are developing plans for dealing with the expected pandemic, and one challenging theme is begging for more public discussion. Some people will be more important than others in fighting the disease as it spreads quickly around the planet, and many more will be left to pretty much fend for themselves.

Who Is 'Essential'?

The top of the list is an easy one. Doctors and nurses will be vital, so they end up in the win column. Others essential to public health and safety will be next, but after that, the going gets tough. A provocative new study argues that the list needs to be broadened. Some truck drivers, for instance, may be just as important as doctors.

"The secondary consequences of severe pandemic influenza could be greater than deaths and illness from influenza itself," according to the study, authored by Nancy E. Kass, professor of bioethics and public health at Johns Hopkins University, and experts from several government agencies.

In a study published in the current journal Biosecurity and Bioterrorism, Kass and her colleagues argue that a pandemic could precipitate societal collapse on many levels, threatening the availability of resources "such as food, water, and gasoline."

What it boils down to is this: Medical professionals won't be very successful if the truck driver doesn't show up with the necessary medications because he couldn't get fuel for his vehicle.

So, people who might have been thought of as nonessential are indeed essential if the wheels of society are to keep rolling along. Someone to deliver fuel to the service station. Someone to keep the truck operational. Someone to drive it.

That doesn't mean every truck driver gets to live. But those who are part of a "minimally functional societal infrastructure" should be near the front of the line.

But how does anyone develop plans that will guarantee cultures continue to function, even as millions are dying? It's a huge challenge.

The Trickle-Down Effect

And, of course, there's the trickle-down effect. It would likely require a presidential decree to designate broadly who gets preferential treatment in response to the disaster. But who's going to make the decision on a community level? The study notes that for any plan to be successful, it must be perceived as "fair," but is that even possible?

Many citizens would likely be told to stay home from their nonessential jobs because the "hallmark" of a pandemic is the ease and speed that a poorly understood virus can spread from one person to another. So, isolation reduces the chance of exposure. But who's going to pay the bills if there is no paycheck?